Hilary Cass' NHS report is rife with debunked theories and falsehoods

On Tuesday evening, Dr. Hilary Cass released a final report commissioned by the NHS, widely expected to target gender-affirming care. The report met these expectations, calling for restrictions on gender-affirming care and social transition, and even advocated for blocking transgender adults under the age of 25 from entering adult care. To justify these recommendations, the review dismissed over 100 studies on the efficacy of transgender care as not suitably high quality, applying standards that are unattainable and not required of most other pediatric medicine. Conducted in a manner similar to the anti-trans review by the DeSantis-handpicked Board of Medicine in Florida, which Cass reportedly collaborated on, the report and its reviews are likely to underpin further crackdowns on trans care globally.

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The 388-page report featured 32 recommendations on how transgender care should be conducted within NHS England. It incorrectly claims that there is “no good evidence” supporting transgender care and calls for restrictions on trans care for individuals under the age of 18, although it does not advocate for an outright ban. The report endorses the idea that being transgender may be caused by anxiety, depression, and OCD issues, despite the American Psychological Association, the largest psychological association in the world, rebutting this as lacking evidence. It also claims that transgender individuals can be “influenced” into being trans, a nod to the discredited theory of social contagion and rapid onset gender dysphoria, rejected by over 60 mental health organizations. Lastly, it seemingly endorses restrictions on transgender people under the age of 25, stating that they should not be allowed to progress into adult care clinics.

To support these recommendations, the report was released alongside “reviews” of the evidence surrounding transgender care, using these reviews to assert that there is "no good evidence" for gender-affirming care. A closer inspection of the reviews released alongside the Cass report reveals that 101 out of 103 studies on gender-affirming care were dismissed for not being of "sufficiently high quality," based on the Newcastle-Ottawa Scale—a subjective scale criticized for its flaws and potential unreliability due to a high risk of bias. This critique is particularly significant given the contentious political nature of the subject and connections between reviewers, Cass, and anti-trans organizations.

The Cass Review seems to have emulated the Florida Review, which employed a similar method to justify bans on trans care in the state—a process criticized as politically motivated by the Human Rights Campaign. Notably, Hilary Cass met with Patrick Hunter, a member of the anti-trans Catholic Medical Association who played a significant role in the development of the Florida Review and Standards of Care under Republican Governor Ron DeSantis. Patrick Hunter was chosen specifically by the governor, who has exhibited fierce opposition towards LGBTQ+ and especially transgender people, and then immediately got to work on targeting transgender care. The Florida review was purportedly designed and manipulated with the intention of having "care effectively banned" from the outset, as revealed by court documents. The Florida Review was slammed by Yale Researchers as “not a serious scientific analysis, but rather, a document crafted to serve a political agenda,” and much of their full critique is applicable to the Cass Review as well.

In those meetings, Cass apparently took interest in Florida’s anti-trans expert report, according to emails from trial exhibits uncovered by transgender researcher Zinnia Jones, such as this email confirming that a meeting took place:

Paul,
See attached information sent to me from the Cass Review. I forgot to mention that they were very interested in the Florida evidence review, especially the report from McMaster University. She recognized the work done at that institution under the leadership of Gordon Guyatt. At Dr. Cass’s request, I sent them a copy of the Florida evidence review.

Notably, Patrick Hunter has been identified as part of a network of anti-trans experts who seek to roll back gains for queer and trans rights by the Southern Poverty Law Center, and both the Florida Review and the Cass Review serve those functions.

One of the most controversial sections of the Cass Review addresses social transition, with the review recommending that individuals considering social transition "be seen as early as possible" by clinical professionals. It claims that social transition could "change the outcome of gender identity development," a statement that notably lacks the validation or evidence level that the review demands of transgender care. Significantly, there has been discussion about prohibiting social transition in schools, even with parental consent. A recent bill proposed by former Prime Minister Liz Truss would have prevented public officials from using language or treating a child "in a manner inconsistent with their sex," leaving unclear how individuals should be treated differently based on their sex.

The Cass Review also touches on gendered toys, suggesting that preferences like trucks for boys and dolls for girls might have a biological basis, despite significant controversy over such claims, with a recent study casting doubt on earlier monkey studies used to justify biological differences in toy preferences. “A common assumption is that toy choice and other gender role behaviours are solely a result of social influences; for example, that boys will only be given trucks and girls will only be given dolls to play with. Although this is partially true, there is evidence for prenatal and postnatal hormonal influence on these behaviours,” writes Cass in the report. To support arguments around potentially high detransition/desistance rates, Cass repeatedly cites Ken Zucker, including the often-challenged “85%” rate from his research. Notably, Zucker has recommended that parents withhold “wrongly-gendered” toys from their children as a strategy to change their gender identity.

Of special note is the focus on those from ages 17-25. The Cass review states that transgender people should not be transferred into adult care until age 25. Among its rationale for doing so is that those who have been waiting for youth care, with waitlists often being over 5 years long, have that waiting time counted towards the wait for adult services. Instead, the review proposes a “follow through” service, declaring transgender 17-25 year old’s as “vulnerable.” It is uncertain what level of restrictions this follow through service would have.

Within a day of the publication of the Cass Review, it appears that those concerns were well warranted. NHS England announced that it would be launching a review into “the operation and delivery of adult GDCs” in a report released by The Guardian. The decision to launch a review into adult care was justified by “concerns put to the [Cass] review team by current and former staff working in the adult gender clinics about clinical practice, particularly in regard to individuals with complex co-presentations and undiagnosed conditions.”

Immediately after the release of the Cass Review, experts in transgender healthcare from around the world voiced their opposition to its findings. Dr. Portia Predny, Vice President of the Australian Professional Association for Trans Health, criticized the findings and recommendations as “at odds with the current evidence base, expert consensus, and the majority of clinical guidelines worldwide.” Similarly, a statement from the Professional Association for Transgender Health Aotearoa condemned the review, noting, “The Review commissioned several systematic reviews into gender-affirming care by the University of York, but appears to have ignored a significant number of studies demonstrating the benefits of gender-affirming care. In one review, 101 out of 103 studies were dismissed.”

It is important to note that gender-affirming care saves lives, and there is plenty of evidence to show for it. Numerous studies have demonstrated that gender-affirming care significantly reduces suicidality, with some showing a decrease in suicidality by up to 73%. A review compiled by Cornell University, which compiled over 50 journal articles on the topic, shows the efficacy of transgender care. These findings were echoed recently in an article published by the Journal of Adolescent Health, which found that puberty blockers dramatically lowered depression and anxiety. All of these studies and more have led to The Lancet, a medical journal with international acclaim, to publish a letter stating that gender affirming care is lifesaving preventative care. The largest and most influential medical organizations support trans care. A recent and historic policy resolution passed overwhelmingly by the American Psychological Association, the largest psychological organization in the world, states that gender affirming care is a medical necessity and that being trans is not “caused” by things like autism and PTSD.

While the full impact of the Cass Review will not be known for some time, it is likely to significantly affect England, where transgender care is already heavily gatekept with extremely long waitlists. Additionally, it is probable that anti-trans organizations in the United States will cite the review to justify further bans on care. However, similar to other "reviews" conducted in countries or states like Florida, where transgender medical rights are under attack, the review is unlikely to be given much credence by many United States judges, legislators in states without significant political opposition to care, and medical organizations that have remained steadfast in combating anti-trans disinformation. Nevertheless, worldwide, the Cass Review carries forward the same types of attacks advanced in Florida, and could have significant negative impacts on transgender people globally should their recommendations be put into effect.

This originally appeared on Erin in the Morning.